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Achieving a High Performance Health System: What Will it Take?

Achieving a High Performance Health System: What Will it Take?. 2006 Priester National Health Conference April 27, 2006 Anne Gauthier Senior Policy Director The Commonwealth Fund www.cmwf.org. Presentation Overview. Current U.S. health care system performance Keys to transforming our system

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Achieving a High Performance Health System: What Will it Take?

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  1. Achieving a High Performance Health System:What Will it Take? 2006 Priester National Health ConferenceApril 27, 2006Anne GauthierSenior Policy DirectorThe Commonwealth Fundwww.cmwf.org

  2. Presentation Overview • Current U.S. health care system performance • Keys to transforming our system • Roles for educators

  3. Commonwealth Fund Commission on a High Performance Health System • GOAL: Move the U.S. toward a higher-performing health care system that achieves better access, improved quality, and greater efficiency, with particular focus on the most vulnerable due to income, race/ethnicity, health, or age. • STRUCTURE: 18 members; Chaired by Jim Mongan, President and CEO of Partners Health Care, Boston, MA; 3 meetings per year • CHALLENGE: The Commission must focus on the “substantive few” critical issues that can accelerate performance improvement in the U.S. health care system. It will need to seek and recommend innovative ways to get these issues onto the public and private policy agendas. • INITIAL PRODUCTS: Chartbook on current performance and briefs on critical national policy issues (available at www.cmwf.org). Framework for a high performance health system (June 2006). Annual performance scorecard (August2006).

  4. Dimensions of a High Performance Health System • Long and healthy lives • Getting the right care • Coordinated care over time • Safe care • Patient-centered care/service excellence • Efficient, high-value care • Affordable care • Universal participation • Equitable care • System has the capacity to improve and innovate

  5. Long and Healthy Lives

  6. Mortality Amenable to Health Care, 1998 Deaths per 100,000 population* * Countries’ age standardized death rates, age 0-74 Note: Includes ischemic heart disease Source: E. Nolte and M. McKee,“Measuring the Health of Nations: Analysis of Mortality Amenable to Health Care,” British Medical Journal, November 15, 2003.

  7. Getting the Right Care

  8. U.S. Adults Receive Half of Recommended Care, and Quality Varies Significantly by Medical Condition Percent of recommended care received Source: E. McGlynn et al. 2003. "The Quality of Health Care Delivered to Adults in the United States,"The New England Journal of Medicine 248(26): 2635–2645.

  9. Provision of Appropriate Care Performance on Medicare Quality Indicators2000–2001 WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI CT WY PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS AK TX LA Quartile Rank FL First Second HI Third Fourth Note: State ranking based on 22 Medicare performance measures. Source: S.F. Jencks, E.D. Huff, and T. Cuerdon. 2003. “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American Medical Association 289(3): 305–312.

  10. Coordinated Care Over Time

  11. 33% Patients in the U.S. Experience Care Coordination Problems Source: Schoen et al., 2005. “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive November 3, 2005. Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

  12. Length of Time With Regular Doctor/Place of Care Source: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

  13. Safe Care

  14. Large Percentage of Adults Report Medication Errors Percent of sicker adults reporting medical or medication error that caused serious health problem in past two years: SOURCE: Schoen et al.,2005. “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive November 3, 2005. Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

  15. Patient-Centered Care/ Service Excellence

  16. Opportunities Exist for Enhanced Doctor–Patient Communication and Interactions Source: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care.

  17. Efficient, High Value Care Cartoonstock.com

  18. Cost and Quality VaryWidely Across Hospitals Source: S. Grossbart, Ph.D., Director, Healthcare Informatics, Premier, Inc. 2003. “The Business Case for Safety and Quality: What Can Our Databases Tell Us,” 5th Annual NPSF Patient Safety Congress, March 15.

  19. Variation in Hospital Mortality and Cost Per Patient Note: The data are based on 10 HCUP states, and the mortality is a weighted composite of 10 risk-adjusted inpatient mortality rates. The cost has been adjusted for wage index, case mix, and severity of illness. Source: H. Joanna Jiang, Ph.D.; Center for Delivery, Organization and Markets; Agency for Healthcare Research and Quality

  20. Affordable Care

  21. Adults with Low and Moderate Incomes Spend High Share of Income onOut-of-Pocket Costs Percent of adults ages 19–64 insured all year with private insurance Note: Income groups based on 2002 household income. Source: Collins, Doty, Davis et al. 2004. “The Affordability Crisis in U.S. Health Care: Findings from The Commonwealth Fund Biennial Health Insurance Survey”. The Commonwealth Fund.

  22. Universal Participation

  23. 24% or more 19–23.9% 14–18.9% Less than 14% Percent of Adults 19-64 Uninsured by State 2003–2004 1999–2000 WA NH ME VT WA NH ME VT MT ND MN MT ND MN OR WI NY MA OR ID SD WI NY MA MI RI ID SD MI RI WY CT PA NJ WY CT IA PA NJ OH IA NE DE OH NV IN NE DE IL MD NV IN WV UT CO IL MD VA DC CA WV UT KS VA MO CO DC CA KY KY KS MO NC NC TN TN SC OK AR SC OK NM AZ AR NM MS AZ AL GA MS AL GA TX LA TX LA FL FL AK AK HI HI Source: Two-year averages 1999-2000 and 2003-2004 from the Census Bureau’s March Current Population Survey (CPS: Annual Social and Economic Supplements). Estimates by EBRI.

  24. Equitable Care

  25. Five-Year Survival Rates for Cancer Patients Vary by Race/Ethnicity and Census Poverty Tract Percent of women diagnosed with cancer, 1988–1994 Source: G. Singh et al. 2003. “Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment and Survival, 1975–1999,” NCI. Figures 6.3 and 6.4.

  26. Medical Home for Children, 2003 Percent of children who have a medical home* ** *Children who have a primary care provider who provides accessible, coordinated and preventive care. ** High income refers to household incomes ≥400% of Federal poverty level; and Poor, <100% of poverty level. SOURCE: 2003 National Survey of Children’s Health; Retrieved from www.nschdata.org

  27. System Capacity to Improve and Innovate

  28. Physicians’ Participation in Redesign and Collaborative Activities, by Practice Size Percent indicating involvement in redesign and collaborative efforts Total 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians Collaborative Efforts* Redesign Efforts * Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

  29. The $2.0 Trillion Question: Q: How are we going to get from where we are to where we could/should be? A: We’re not, unless we change the way we play the game

  30. Key Pieces to Transforming the U.S. Health Care System • Achieve universal participation • Organize care and information around the patient • Expand primary care and preventative services • Expand use of interoperable information technology • Reward performance • Enhance quality and value of care • Encourage collaboration

  31. Universal Participation 1. Achieve Universal Participation

  32. Growing Number of Uninsured and Underinsured Americans Uninsured All Year 13% Insured All Year, Not Underinsured 65% Uninsured Part Year 13% Underinsured 9% Uninsured is defined as uninsured for some time during the past year. Underinsured defined as family out of pocket expenses represent at least 10% or more of income, family out of pocket expenses for low-income represents at least 5% of income or deductibles represent 5% of income Source: C. Schoen et al. 2005. “Insured but Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, June 14, 2005. Based on The Commonwealth Fund 2003 Biennial Health Insurance Survey.

  33. Uninsured and Underinsured are More Likely to Have Access Barriers, Problems with Medical Bills and Be Dissatisfied with Care Percent Experiencing Problem in Past Year Problems With Medical Bills Access Barriers Due to Cost Source: C. Schoen et al., 2005. “Insured but Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, June 14, 2005. Based on The Commonwealth Fund 2003 Biennial Health Insurance Survey.

  34. Options for Expanding Coverage • Mixed public insurance/private insurance strategy • Improve coverage • Ensure adequate benefits • Provide financial protection • Expand public programs • Federal Employees Health Benefits Program • Medicare • State Children’s Health Insurance Program • Provide financial assistance to workers and employers to afford coverage • Pool purchasing power to make coverage more affordable • Promote new benefit designs to make coverage more affordable • Mandate employers to offer and/or individuals to purchase coverage; subsidize those below x% of poverty

  35. Organize Care and Information Around the Patient 1. Achieve Universal Participation 2. Organize care and Information Around the Patient

  36. Those with Less Choice of Where Medical Care Is Received Are Less Likely to Be Satisfied with Their Health Care Percent of adults 19–64 with employer-sponsored insurance who are “somewhat” or “very dissatisfied” with their health care Source: Jeanne Lambrew 2005. “Choice’ in Health Care: What Do People Really Want?” The Commonwealth Fund, September 2005.

  37. Options for Organizing Care and Information Around Patient • Insurers and providers can promote shared decision making by: • Providing tools to assist with health care decisions (e.g., videotapes, booklets, websites) • Providing follow-up counseling with skilled staff • Requiring shared decision-making education for elective procedures • Making personal health records and data accessible to patients and their providers • Purchasers can reward plans that emphasize patient-centered care

  38. Expand Primary Care and Preventative Services 3.Expand Primary Care and Preventative Services 1. Achieve Universal Participation 2. Organize care and Information Around the Patient

  39. Expand Primary Care and Preventative Services • Health is better in areas where more primary care physicians • People who receive care from a primary physician are healthier • Major features of primary care are associated with better health • “A greater emphasis on primary care can be expected to lower the costs of care [affordability], improve health through access to more appropriate services [right care], and reduce the inequities in the population’s health [equity].” Source: Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3):457-502.

  40. Options for Expanding Primary Care and Preventative Services • Restructure payment and benefit design to emphasize primary and preventative care • Promote primary care vs. specialty care • Raise status of primary care providers

  41. Expand Use of Interoperable Health IT 3.Expand Primary Care and Preventative Services 1. Achieve Universal Participation 2. Organize care and Information Around the Patient 4. Expand Use of Interoperable Health Information Technology

  42. Over 80% Medication Errors Prevented with Computerized Order Entry System Adapted with permission from D.W. Bates et . al. 1999. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” Journal of the American Medical Informatics Association 6(4):313-21.

  43. Options forExpanding Use of Interoperable Health IT • Many activities underway in private and public sectors • Possible roles for government include: • Provide incentives for providers to improve health care performance • Pay for providers to acquire technology, especially those in small, rural or safety-net institutions • Eliminate dysfunctional restrictions on market transactions • Use muscle as large purchaser to require uptake of HIT

  44. Reward Performance 3.Expand Primary Care and Preventative Services 1. Achieve Universal Participation 2. Organize care and Information Around the Patient 5. Reward Performance 4. Expand Use of Interoperable Health Information Technology

  45. Improvement in Doctors’ Cervical Cancer Screening Rates After Implementation of Quality Incentive Program Percent improvement in cervical cancer screening rates among physician groups (Intervention group) (Control group) Source: M.B. Rosenthal et al. 2004. “Early Experience with Pay-for-Performance: From Concept to Practice,” JAMA 294(14): 1788-93.

  46. Building Quality Into RIte CareHigher Quality and Improved Cost Trends Cumulative Health Insurance Cost Trend Comparison Percent • Quality targets and $ incentives • Improved access, medical home • One third reduction in hospital and ER • Tripled primary care doctors • Doubled clinic visits • Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care RI Commercial Trend RIte Care Trend Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003.Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.

  47. Pay for Performance Programs • There are almost 90 pay-for-performance programs across the U.S. • Provider driven (e.g., Pacificare) • Insurance driven (e.g., BC/BS in MA) • Employer driven (e.g., Bridges to Excellence – Verizon, GE, Ford, Humana, P&G, and UPS) • Medicare • 2003 Medicare Rx legislation demonstrations of Medicare physicians a per-beneficiary bonus if specified quality standards are met • Medicaid • RIte Care will pay about 1% bonus on its capitation rate to plans meeting 21 specified performance goals • 4 other states built performance-based incentives into Medicaid contracts – UT, WI, IO, MA • Evaluation of impact still pending Source: Leapfrog report for Commonwealth Fund; additional information available at http://www.leapfroggroup.org/

  48. Options for Rewarding Performance • Assuring a “business-case” for investing in high performance • Financial incentives • Pay-for-Performance (P4P) • California’s Integrated Healthcare Association (IHA) is the current benchmark for a statewide effort (www.iha.org) • Tiered networks, co-pays • Non-financial incentives • Public reporting • MHQP (Massachusetts Health Quality Partners); California (CalHospitalCompare.org) • Recognition

  49. Enhance Value and Quality of Care 3.Expand Primary Care and Preventative Services 1. Achieve Universal Participation 2. Organize care and Information Around the Patient 5. Reward Performance 4. Expand Use of Interoperable Health Information Technology 6. Enhance Value and Quality of Care

  50. Transitional Care ReducesRehospitalization for Heart Failure Patients Resource use among congestive heart failure patients ages 65+ treated atsix Philadelphia hospitals during 1997–2001 who were randomly assignedto receive a three-month transitional care intervention or usual care Usual care group Intervention group Percentage of patients who were rehospitalized or died Number ofhospital readmissions Average cost of care Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leathermanand D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005,The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf.

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